Delivering essential services The State Policy Road Map: Solutions for the Journey Ahead

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​Can human services go beyond just transactional service delivery? How can state leaders tackle issues within the education sector? Will affordable access to quality health care become realistic for all? State institutions may need to rethink their role to find answers to these tough questions.

Health care: Improving outcomes, controlling costs

By Melissa Majerol, Jim Hardy, and Lindsay Hough

Explore: K–12 education | Higher education | Human services

What is the issue?

States have long played a significant role in the health care of their residents, but that role has increased dramatically over the last few years. Under the Affordable Care Act (ACA), millions of poor and low-income people have gained health insurance through Medicaid and the ACA Marketplace.1 Many states are grappling with how to ensure access to quality health care for low-income and vulnerable populations as well as those who buy their own insurance, while at the same time controlling rising premiums and underlying health care costs.

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Government reform

The challenges that could change everything

Emerging trends

Ten bold plays

Improving quality of life

Alongside these changes, many states are facing an unprecedented opioid crisis, a challenge not only for the health care system, but often also for law enforcement, the child welfare system, and communities at large. Certain parts of the country have been hit particularly hard, but no state is immune to the impacts of this epidemic.2 The crisis is far-reaching, with nearly half of all Americans saying they know someone who has been addicted to prescription painkillers,3 and more than 60 percent saying that federal and state governments aren’t doing enough to fight the problem.4

Against this backdrop of new challenges, many chronic health issues persist, including obesity, diabetes, and mental health conditions. Among the most costly are individuals with multiple chronic conditions—27 percent of Americans have multiple chronic conditions, but a much larger chunk, 66 percent, of total health care spending is directed toward their care.5 There is a growing recognition that many such health issues are strongly linked to socioeconomic factors (for example, income, education, living and working conditions, and numerous other environmental factors) collectively referred to as the social determinants of health.6

These challenges are complex, and each state’s circumstances are unique. But there are numerous strategies that could help states tackle some of their most pressing health care issues.

Issue by the numbers: Health care

  • Nationwide, nearly 20 percent of individuals are enrolled in Medicaid—a 29 percent increase since 2014 when the ACA Medicaid expansion provision was implemented.7
  • In recent years, Medicaid’s share of state budgets has been on the rise:8
    • 11.7 percent in 2001
    • 13.3 percent in 2011
    • 15.8 percent in 2015
  • Following the establishment of the ACA Marketplaces in 2014, states have seen significant variability in annual premium increases. For example, between 2016 and 2017, the average premium change in the Marketplaces ranged from a 4 percent decrease in Indiana to a 145 percent increase in Arizona.9 The White House and Congress continue to consider executive actions and legislation that could impact the Marketplaces. An area of ongoing focus is the federal cost-sharing reduction subsidies (CSRs), which are paid to health insurers to offset deductible and out-of-pocket expenses for low-income individuals who qualify.
  • Research shows that social circumstances (including income, education, and living and working conditions) and environmental exposure account for 20 percent of premature deaths. Health care (10 percent), behavioral patterns (40 percent), and genetic disposition (30 percent) account for the remaining 80 percent.10
  • Opioids contributed to nearly 34,000 deaths in 2015, and opioid overdoses have quadrupled since 1999.11

How can state leadership tackle the issue?

Consider using waivers to experiment with Medicaid and Marketplace innovations

Most states have at least one Medicaid 1115 demonstration waiver. The purpose of these waivers is to allow states to waive certain federal Medicaid rules and experiment with new policies such as expanding eligibility, providing services not typically covered, and using innovative delivery systems that seek to improve care, increase efficiency, and reduce costs.12

The ACA equivalent of the 1115 waiver is the 1332 state innovation waiver, which became available to states in January 2017. This waiver aims to give states the flexibility to innovate in the health insurance market while retaining the basic protections of the law.13

Bringing a waiver from concept to implementation can be achieved in three phases:

  • Strategy. States should align their waiver initiatives with their overall Medicaid goals while also assessing the likely impact the waiver could have on other important areas such as the local economy or the social determinants of health. The strategy phase is also a good time to engage stakeholders and to ensure that the initiative is operationally feasible.
  • Design. It is important to develop a structured, planned approach to manage all aspects of waiver initiatives across technology, policy, and human capital; and come up with the best solution against existing infrastructure, policy, and agency operations.
  • Implementation: States should provide technical, operational, and policy insight to support implementation. They should also effectively engage, communicate, and train stakeholders affected by the waiver initiative and use technology solutions, where appropriate, to engage members and stakeholders.

To learn more, see Deloitte's study on how states are moving forward with Medicaid and ACA waivers.

When developing policies and proposals for a Medicaid or ACA waiver, it can be useful to see what has and hasn’t worked in other states, while recognizing that each state’s goals and circumstances might differ. And when implementing a change to Medicaid or the Marketplace through a waiver, it is important to rigorously collect data and evaluate results to ensure that good ideas can be replicated.

Explore value-based care (VBC) transformation

The predominant form of health care payment in the United States across public and private payers is fee-for-service,14 in which providers are paid for every consultation, exam, and procedure, regardless of the health outcome. Fee-for-service is often considered inefficient because it incentivizes volume over value.15 A more aspirational goal is to pay less for health care by preventing illness while at the same time improving health outcomes overall.

To learn more, see Deloitte's study on Alternative payment models in Medicaid.

In an effort to transition from a payment model-based volume to one based on value, many states have begun experimenting with a variety of Medicaid alternative payment models (APMs), including patient-centered medical homes (PCMHs), Medicaid health homes, episode-of-care payments, and accountable care organizations (ACOs). Some of these models focus on the coordination of health care services by a team of health professionals to improve health outcomes and avoid unnecessary or harmful redundancies. Others incentivize care teams to improve health outcomes and reduce health care utilization by providing capitated payments to take care of a particular patient with a specific illness.

States that are exploring VBC for their Medicaid program can learn from other states that are already moving down that path. Consider these lessons:

  • Know your market. States should consider their unique populations, stakeholders, delivery systems, and political environment when developing a vision for the new program. Design a program that providers and health plans can realistically administer and oversee.
  • Keep the program design simple. New payment models can quickly become overbaked and complex. The more complicated the model, the more difficult it will be to implement. Keep it simple at first and, if necessary, introduce more complex components after initial implementation.
  • Determine how you will access, aggregate, and analyze data. A VBC program relies on accurate and meaningful data to achieve its goals. New analytic solutions or system upgrades might be needed.
  • Expect the unexpected, reflect, and refine. It is important to build time and space into the process to accommodate nuances. Incorporate successes and lessons learned into the program implementation.

Consider using a "healthy community funding hub" to address complex problems

Health care is typically about much more than just medical care. The opioid and broader substance abuse crises, for example, impact not only health care providers, but often also human services, criminal justice, and child welfare. Health care is only one factor that contributes to health outcomes. Various social determinants of health—including housing, transportation, nutrition, education, and working conditions—can also influence well-being.

To tackle these complex problems, disparate agencies, health care providers, and community groups can and should work together. But such groups aren’t necessarily used to communicating, pooling resources, and launching coordinated initiatives. Health care providers and law enforcement might be expending significant resources to address substance abuse and addiction in their communities. But without a coordinated response, they could be duplicating efforts—or worse, working at cross-purposes.

To align strategies and funding, states can work with counties and localities to establish healthy community funding hubs, a concept developed by the non-profit Trust for America's Health (TFAH). The purpose of a healthy community funding hub is to break down the walls between agencies in order to pool funds and other resources, and to develop coordinated responses that impact the community. To that end, the hub would:

  • Provide financial management and oversight to coordinate multiple funding sources
  • Govern the prioritization of spending on evidence-based interventions to ensure accountability to the target community
  • Serve as a trusted fiscal intermediary between sectors that are related to health care

Read more about how human-centered design can improve the citizen experience:

Fighting the opioid crisis
Fighting the opioid crisis
Supporting healthy communities
Supporting healthy communities

Consider updating data systems and developing advanced analytics

Because of Medicaid’s sheer size, states and the federal government are often under tremendous political and economic pressure to ensure that the program is run efficiently and effectively. Doing so through payment and delivery system reform and quality measurement typically requires advanced data capabilities.

For states, the first step toward advancing analytic and data capabilities is likely to upgrade their analytics platform. Legacy systems typically were not built to support the advanced analytics usually required to operate a modern Medicaid program. Many were built based on fee-for-service claims processing operations and didn’t explicitly take tracking processes and outcome measures into account.

As states begin to upgrade their data infrastructure, many are doing so with a broader vision of building an integrated data environment that is interoperable with electronic health records (EHRs) and other agencies and organizations, including social services, public health, and the department of corrections. The federal government has shown its support by offering Medicaid programs a 90 percent contribution to system upgrades that support interoperability, which could advance Medicaid program goals.16

While an upgraded analytics platform might be a necessary first step, it alone won’t allow Medicaid agencies to become data-driven organizations. For that, they’ll likely also need to ensure data quality and adopt self-service capabilities. In other words, agencies should first ensure that their data is accurate, then build software interfaces that can broaden the access and use of the data. Third, collecting the right data and setting clearly defined priorities—be it decreasing emergency room utilization, lowering obesity rates, or reducing the number of diabetes-related hospitalizations—could help deliver results.

To learn more, see Deloitte's study on Organizing for analytics in health care.

Lastly, states should consider establishing a strong analytics team to run the analyses, build effective models, and support the Medicaid operation to drive new payment models, reduce costs, and improve outcomes. Whether a state’s data capabilities are in-house, under contract with an outside vendor, or both, they should ensure they build a capability that can be sustained over the long term.

You don’t need to look too far for inspiration

Minnesota's 1332 state innovation waiver

Minnesota's approved 1332 waiver allows the state to use ACA funds to help establish a reinsurance program designed to reduce the cost of premiums in Minnesota’s ACA Marketplace.17 Prior to the waiver being approved, insurers in the state filed two sets of rates, one under the reinsurance program and the other without one. In the absence of the reinsurance program, health plans intended to increase premium rates by between 3 percent and 32 percent from the previous year. With reinsurance, three out of four Marketplace plans will decrease their rates; one will increase their rate by under 3 percent.18

Oregon’s coordinated care organizations

In 2012, Oregon established 16 coordinated care organizations (CCOs) to serve its Medicaid population through an ACO-like model.19 CCOs consist of networks of providers (physical and behavioral health, and dental care) who work together to serve their patients, and receive capitated payments.

Research funded by the National Institutes of Health (NIH) found that CCOs were associated with a 7 percent relative reduction in service expenditures, attributable primarily to reductions in inpatient utilization, and reductions in avoidable emergency department visits. CCOs also exhibited reductions in primary care visits (a potential area of concern),20 but increases in timely prenatal care.21

Pennsylvania’s adoption of advanced data capabilities

According to federal regulation, states that contract with managed care organizations (MCOs) are required to develop and enforce provider network adequacy standards that include minimum time and distances between beneficiaries and providers.22 Pennsylvania is using advanced data analytics based on geospatial information systems (GIS) to map beneficiaries and providers to determine whether MCOs are complying with federal time and distance requirements and where the gaps need to be filled.23

K–12 education: Old debates yielding to new realities

By Allan Ludgate and John O’Leary

Explore: Health care | Higher education | Human services

What is the issue?

K–12 education is an important issue for governors for two major reasons. First, voters care passionately about their children’s education. Second, a well-educated population is an important foundation for economic prosperity.

In 1983, America’s education world was shaken up by the report A Nation at Risk, with its memorable introduction:

“If an unfriendly foreign power had attempted to impose on America the mediocre educational performance that exists today, we might well have viewed it as an act of war.”24

This report was considered shocking by many because the United States had long expected top-notch results from its education system. In the words of the report, it was “unimaginable” that other nations would match or surpass the United States’ educational attainments.

Today, our nation is no longer at the top of the global education standings. Though the United States spends a greater proportion of its GDP on education than other OECD countries, it generally ranks in the middle of the pack in terms of math and reading scores.25

Since 1983, the K–12 education landscape has been marked by political battles as well as a wide array of reforms, including the federal No Child Left Behind effort. As technology evolves and experimentation of various sorts provides data to guide reform, we are likely to see a continued focus on educational innovation.

While there is no shortage of political disagreement on the topic, there is one aspect of education policy upon which both Democratic and Republican governors seem to agree: States should lead and the federal government should allow them to do so. In 2017, the National Governors Association released a policy statement on education that stresses this point: “Governors believe federal education policy should embrace a stronger state-led accountability system . . . [federal law should] recognize the proper, leading role of governors and other state officials to collectively govern education.”26 That shift back to states appears to be already underway, as the Every Student Succeeds Act, which became law with bipartisan support in December 2015, gave states greater flexibility in terms of setting standards as well as in the areas of curriculum, pedagogy, and teacher professional development.

Issue by the numbers: K–12 education

  • In 2016, an estimated 19.4 percent of total state expenditures went toward elementary and secondary education.27
  • Enrollment in private schools as a percentage of total K–12 enrollment has declined somewhat, from 11.2 percent in 2003 to just 9.8 percent in 2013.28 Over a similar period, between 2003 and 2012, homeschooling has also increased from 2.2 percent to 3.4 percent.29
  • As shown in figures 1 and 2, fourth-grade student achievement has been average and mostly flat over the last 17 years in both mathematics and reading.

United States fourth-grade National Assessment of Educational Progress (NAEP) mathematics average scores

United States fourth-grade National Assessment of Educational Progress (NAEP) reading average scores

  • The inflation-adjusted cost per student has leveled off at about $12,500 after several decades of increase (figure 3).30

Cost per pupil in US K–12 schools

  • In 2015, the Programme for International Student Assessment31 placed the United States at the 38th spot out of 71 countries in math and 24th in science, though these average figures may mask disparities in achievement based on income, race, and other factors.32
  • As shown in figure 4, several states should be anticipating significant increases in public school enrollment between 2014 and 2026.33

Projected percentage change in US public elementary and secondary school enrollment between fall 2014 and fall 2016

How can state leadership tackle the issue?

Education reform used to center on changes to traditional K–12 schools. Today, education innovation seems to be a much broader term. Rethinking education often starts with rethinking potential learners, from the very young through children in secondary school to people in their working adulthood. It also may mean reconsidering the notion of a public school, requiring fresh thinking about school governance approaches as well as about ways to deliver an effective education experience to students, teachers, and parents.

Coming to school ready to learn

Education doesn’t happen in a vacuum. Children grow up in an ecosystem of their family, community, and school. Closing the economic achievement gap has been a regular goal of educational policy and education philanthropists alike, but the debate has often been framed as one of “fixing schools” or “fixing poverty.” Too often for children growing up in poverty, however, these three dimensions can reinforce each other in a negative way.34

The challenges of school preparedness and family dysfunction are real, and work is being done to ensure students arrive at school “ready to learn.” Some states, such as Michigan, are taking steps toward greater involvement in pre-K education to help children be ready to learn when they arrive at school.

The 21st Century Michigan Education Commission

In 2016, Michigan governor Rick Snyder issued an executive order establishing the 21st Century Michigan Education Commission. Composed of a wide array of education and business leaders, the commission’s report addressed educational issues that go well beyond the traditional classroom.

The commission’s recommendations encompassed a broad view of the state’s education mandate. The report notes: “Michigan’s 21st-century economy and educational goals require an education system that is seamless and accessible to all, from prenatal through career.” The report’s recommendations included:

  • Connect human services to schools: “Michigan must embed human services in schools and strengthen links between schools and community-based human services in order to connect children, students, and their families with the right services at the right time.”
  • Enhance teacher preparation: “The state must increase requirements and improve training for preservice teachers. This means that all teacher preparation programs must set higher standards for admission, require a year-long residency, and require evidence of skills in their subject matter, social-emotional intelligence, and pedagogy.”
  • Adopt performance benchmarks: The report advocated the adoption of “statewide P-20 performance measures that are benchmarked against high-performing states and nations.”
  • Invest early: “Support universal pre-K for all four-year-olds.”
  • Educational options: “Ensure that all schools are high-quality and that every student has access to a high-quality school, including traditional public schools, cross-district choice, charters, and online learning options.”35

Teacher effectiveness and technology

Teacher quality is widely viewed as one of the most important variables in student success. Numerous reforms have been advanced to improve the situation, from curtailing tenure to just-in-time professional development. Other reforms have focused on measuring teacher performance—something that can be very difficult to do—in order to effectively implement pay for performance.

A combination of live instruction and digital augmentation tools may help to boost the effectiveness of teachers through the enhanced use of technology. Digital education materials include educational software, games, videos, podcasts, and other media that can be accessed through laptop and desktop computers, tablets, and mobile phones.

Deloitte’s 2016 Digital Education Survey found that many teachers, parents, and students are embracing these tools with enthusiasm, and a majority of these stakeholders believe that “digital education” makes a positive difference in learning outcomes and experiences.36

The survey found that at present 80 percent of teachers use digital education at least once a week, and 75 percent of teachers believe that digital content could replace print textbooks within the next decade. The biggest hurdle to adoption? For teachers, lack of training appears to be one of the biggest barriers to use of educational technology inside and outside the classroom.37

Digital student engagement for lifelong learners

Thanks to the advanced technologies available today, it is possible to securely deliver instructional content personalized to an individual student’s ability, interest, and learning style. As a case in point, Khan Academy’s “anytime, anywhere” educational model delivers personalized learning to students worldwide and even provides diagnostics and dashboards to teachers.

However, merely adding technology to the classroom might not be enough. Participants in the education ecosystem—school administrations, teachers, students, parents, edtech solution providers, and government educational agencies—could work more closely together to create new digital learning environments. Integrated next-generation technologies will likely make it easier for students of all ages and backgrounds to continue their education for their entire lives, both inside and outside the classroom.38

Making every dollar count for learning

Roughly 40 cents of every public education dollar goes to noninstructional costs—physical infrastructure, food service, security, and so forth.39 A variety of approaches exist that could reduce these costs, potentially allowing states to devote more resources directly to learning.

For example, states can provide incentives for school districts to utilize a shared services approach in which, rather than having each district contract separately for items such as bus transportation or heating oil, the districts could join together to realize economies of scale. Oregon’s Reset Cabinet report estimated that the state could save $40 million a year if school districts shared certain services.40

You don’t have to look too far for inspiration

Delaware Pathways

Closing the workforce skills-employability gap could be important to economic competitiveness. In the past, most governors were either “workforce governors” or “education governors,” but in some cases, these priorities may converge.

Delaware's Pathways initiative is an integrated collection of programs and services intended to enhance the “academic, technology, and employability skills” of secondary school students in Delaware. As part of the national Pathways to Prosperity network, the Delaware initiative seeks to prepare students for high-demand, high-opportunity jobs by linking education and work experiences.41

Higher education: New models for the future

By Jeff Bradfield, Tiffany Fishman, and David Noone

Explore: Health care | K–12 education | Human services

What is the issue?

To maintain economic prosperity, a state needs well-educated citizens. State governments can help to influence the higher education landscape so that it better serves the needs of students, employers, and the population as a whole. Both directly through state institutions and indirectly through economic development initiatives, loans, and other programs, state leaders can have considerable influence on the higher education.

Higher education has changed considerably over the years, shaped by several macro-level trends:

  • Student demographics: Compared with traditional college students who arrive straight from high school, attend college full-time, and graduate in four years, many students today are older, have lower incomes, and carry more adult responsibilities. Often, they’re the first in their families to go to college. A good number speak English as a second language. These individuals often need very different kinds of support than students in the past.
  • Workforce needs: According to ManpowerGroup, 46 percent of employers report being unable to find skilled workers to fill open jobs.42 To acquire skills that match employers’ needs, many students today are looking beyond traditional higher education to alternatives such as “nanodegrees” powered by massive open online courses (MOOCs), or short-term, immersive boot camps to provide just-in-time workplace skills.
  • Pressure on institutions: The cost of college tuition has risen by 538 percent since 1985, compared with an increase of just 121 percent in the consumer price index during that period.43 According to one Pew Research Center survey, the millennial generation (defined by Pew as Americans aged 18 to 33) is dealing with higher levels of student loan debt, poverty, and unemployment, and lower levels of wealth and personal income, than the two preceding generations at the same age.44 Many colleges and universities are under pressure to reduce costs and to document the return on investment they provide.

Issue by the numbers: Higher education

  • Today, 44 percent of college and university students are 24 years of age or older. Thirty percent attend class part-time, 26 percent work full-time while enrolled, and 28 percent take care of children or other dependents while pursuing their postsecondary studies.45
  • On top of that, 52 percent of college and university students are the first in their families to seek higher education, 42 percent come from communities of color, and 18 percent are non-native English speakers.46
  • The “sticker” price tag for a traditional four-year residential degree program has almost doubled in the last decade. The cost of tuition, fees, and room and board at out-of-state public universities now averages just over $35,000 per year; for private nonprofit universities, the average cost is more than $45,000 per year.47
  • The cost of college tuition has risen by 538 percent since 1985, superseding household income gains (figure 5).48

College tuition growth has vastly outpaced income gains

  • On average, states spent $1,448 (16 percent) less per student in 2017 than in 2008.49 Nearly every state has shifted the cost to students in the last 25 years (figure 6).50

Students are funding a larger share of education after recessions

  • States spent about 10 percent of their general funds on higher education in fiscal year 2015, compared with 11.5 percent in the postrecession period (fiscal year 2009).51

How can state leadership tackle the issue?

Be thoughtful about coordinating assistance to nontraditional students

Financial aid programs that help with tuition and academic costs are as important as ever. But nontraditional students could also need other support, such as help paying for child care, transportation, and food. States should consider aligning public assistance programs with the needs of adults who attend schools and making public benefits easily accessible for those students who qualify.

Think more broadly about financial aid

In the future, students will consume education in many different ways—in the classroom, online, in full semesters, in short bursts, on the job, and through one-on-one mentoring, to name just a few. Most likely, these learning experiences will continue throughout a person’s career. Given that reality, state financial aid programs should consider making a wider variety of educational experiences eligible for aid.

Encourage state university systems to explore new options for instruction

Many institutions of higher learning today are experimenting with a broad range of new approaches, such as blended learning, adaptive learning, and competency-based education. New strategies for keeping nontraditional students on target to succeed are emerging as well. These include data-driven systems for detecting when a student needs extra help, tutoring and coaching programs to provide that help, and class schedules that make attending school easier for students who also hold down jobs, manage families, and rely on public transportation. State university systems should promote experimentation to find new solutions.

Reimagining higher education
Read more about how state university systems can explore different models of instruction in Reimagining higher education.

Focus on the student

Every year across the United States, a significant number of students fail to complete their college degrees. “While it is true that retention programs abound on our campuses, most institutions have not taken student retention seriously,” noted Vincent Tinto, distinguished university professor emeritus in the School of Education at Syracuse University.52 Colleges and universities should adapt to the needs of a diverse, dynamic, and changing student population by providing flexible services and a greater sense of connection.

Steps can be taken to deploy new learning methods, develop comprehensive support services, streamline student-facing operations, and pursue strategic partnerships with employers and other entities. These efforts would help the state to train the workforce of tomorrow, reduce the time to graduation, and decrease the dropout rate.

Success by design
Read more about how state university systems can effectively support their students in Success by design.

Strengthen the pathways from education to employment

Early college or dual enrollment programs can provide a bridge for high-school students who want to get a jump on their higher education, including students who need some extra help to prepare for college-level work. Public institutions can smooth students’ progress by agreeing on common course numbering systems and providing clear transfer pathways between two- and four-year colleges. And while students work toward their undergraduate degrees, co-op, internship, and apprenticeship programs can provide opportunities to earn money while honing skills that could make them attractive to employers in their chosen fields.

You don’t need to look too far for inspiration

Course Signals at Purdue

At Purdue University, some courses employ Course Signals, a software platform that uses data analytics to calculate and track student progress and provide early warnings to both students and faculty. Students receive notifications about how they are performing in a course as they progress through it. Faculty who receive this performance data are able to identify students who may need additional assistance to succeed and can target interventions to ensure that at-risk students stay on track. Students enrolled in Course Signals classes at Purdue have a 21 percent higher graduation rate than those enrolled in courses that don’t use the software.53

Low-cost computer science at Georgia Institute of Technology

Rather than trying to be all things to all people, some universities are beginning to carve out niches in the market for higher education, shedding unnecessary costs and better differentiating themselves from their peers.54 Georgia Institute of Technology, for example, has focused on providing the lowest-cost options in fields undergoing a rapid growth in demand. MOOC provider Udacity, in collaboration with AT&T, is powering Georgia Tech’s first accredited online master’s program in computer science with a price tag of just $7,000.55

Adaptive learning at Arizona State

To help new students who were not college-ready in mathematics, Arizona State University launched a math readiness program in the fall of 2011. This program uses adaptive learning technology to let students work through the program at their own pace, aided by an instructor.56 The program’s initial results showed improved outcomes, with fewer student dropouts, increased pass rates, and lower course completion times.57

Building bridges to college in Ohio

In the Appalachian region of Ohio, Zane State College and the Zanesville City Schools have created a program to help high-school seniors who have grade point averages of 3.0 or higher, but whose tests show them to be unprepared for college. The program includes career exploration, tutoring, mentoring, and a one-semester class on college success taught at the high school by college faculty. Participants also take college math and English courses for dual credit, and each student goes to the college to take a course specific to his or her major.58

Human services: Rethinking delivery for greater impact

By Sundhar Sekhar, John O’Leary, and Tiffany Fishman

Explore: Health care | K–12 education | Higher education

What is the issue?

Although its core mission is to improve the trajectory of people’s lives, human services has long been more transactional than transformational.

For most human services programs, the business day consists of programmed actions and reactions, inputs and outputs, moving back and forth among government workers, their data systems, and their clients. In executing complex human services policies, success is defined primarily by the timeliness and accuracy of these transactions rather than their results. This has led to a model in which outcomes are in fact merely outputs: Did we issue food stamps in a timely fashion? Did we respond to 95 percent of our hotline calls within 24 hours?

Rather than identifying and addressing the problems that bring individuals and families into contact with the social safety net, human services programs instead tend to see people through the lens of eligibility: Clients are enrolled in eligible programs, which means there is a particular set of services they can receive, even if those might not be the ones they really need to improve their situation. This program-centric view is a lingering byproduct of the way human services programs were originally created—as stand-alone programs rather than as an integrated safety net.

Thanks to advances in technology and analytical techniques, human services agencies are now poised to move beyond transactional service delivery. If agencies can put their data in front of both clients and caseworkers in a way that they can readily understand, and in time use the data in a way that affects results, then what was once a transactional business model can become a transformational one, capable of achieving potentially life-changing outcomes in an efficient and cost-effective manner. Instead of executing mundane tasks, social workers can focus on families and the help they need.

Issue by the numbers: Human services delivery

  • Child support has become an increasingly important lifeline for impoverished families. Child support represents 41 percent of the income of poor families that receive child support payments, up from just 29 percent a decade prior.59
  • By introducing no-touch (self-service) and low-touch options for determining eligibility for health and human services programs, one state automated 78 percent of its daily applications, reducing processing times by 35–50 percent and saving a projected 1 million hours in labor.60
  • In Camden, New Jersey, residents in just two buildings accounted for $200 million in medical services from January 2002 to June 2008. That’s more than $30 million every year from just two buildings.61 By better coordinating these clients’ health care and addressing their social circumstances, the Camden Coalition of Healthcare Providers was able to cut these costs by more than half.62

How can state leadership tackle the issue?

Accelerate the value of self-service through automation

Advances in technology are significantly reducing manual processes and the need to manipulate reams of paperwork. These advances can free up caseworkers to focus their time and attention on providing specialized case management for clients, rather than becoming enmeshed in what they need to do to take care of transactional tasks and processes. Automation enables labor-saving innovations such as self-service eligibility portals, and back-end systems that can refer clients to services with little or no caseworker involvement. In some instances, outdated policies haven’t kept pace with new technologies, such as allowing for electronic correspondence with photo attachments or tele-interviews, which are more easily automated than paper-based processes.

Identify opportunities for RPA technologies to automate administrative tasks

Robotic process automation (RPA) technologies automate repeatable, rules-based tasks. Unlike a typical automated system function, RPA software, also known as a “bot,” operates at the user interface level and mimics the activities of a caseworker as it interacts with multiple applications in the execution of a task.

Take the foster family application process, in which repetitive tasks can eat up hours. Imagine having a bot take a scanned foster family application, enter it into the appropriate system, and even validate in a separate system to determine if a mandatory lead inspection was completed in the home. This not only frees up the caseworker to spend more time determining if the home meets quality expectations, but also retrieves the lead inspection information without needing to build a data link to a separate system.

This is just one example. The challenge is to look for low-risk, high-volume, repetitive tasks that traditionally take valuable time away from the caseworker and support staff, and give those tasks to the bot.

Redesign programs to serve unique customer segments

Just as businesses break their larger customer populations into subgroups with similar characteristics, human services programs too can segment their client bases. The goal is to deliver the right services to the right people. By rethinking the design and delivery of programs, human services agencies can better understand the diverse spectrum of needs among individual citizens and families. This can move human services systems from a “one-size-fits-all” approach to a “right-size-for-all” way of thinking about customers and what they need.

Transform practice through analytics

Enhanced data collection, coupled with the proliferation of agile and inexpensive technologies, is allowing for the increased use of analytics. This shifts the focus of human services from “hindsight” to “foresight and insight,” which can offer unprecedented opportunities for efficiencies and cost savings. It can also make sure that the right solutions get to the right people at the right time.

Extend caseworker capabilities using AI-based technologies

The introduction of artificial intelligence (AI) can bring big changes to human services agencies, freeing caseworkers to focus on life-changing work. AI can also help them to do a better job, providing the insights necessary to do the right work, for the right people, at the right time, thus achieving meaningful results for the individuals and families they serve.

To make the most of AI investments, agencies should consider redesigning their talent strategies so that a job is viewed not as an individual production function, but rather as a collaborative problem-solving effort, where a human defines the problems, machines help find the solutions, and the human verifies the acceptability of those solutions.63 Chatbots are another way to provide clients with smart guidance on questions about eligibility and policy, improving accuracy without tying up human resources. In addition, digital workflows can also augment worker impact through data analytics and behavioral “nudging.”

You don’t need to look too far for inspiration

Data-driven child support enforcement in Florida

The Florida Child Support Program uses a predictive model to select compliance actions that will produce the best return on investment (ROI), bringing in the most collection money when compared with the costs. The model is based on two specific parameter groups—the financial compliance levels of cases and the indicators of the parents’ ability to pay (criminal history, employment, institutionalization status, and disabilities). For each case, the system then identifies the best course of action, selecting and prioritizing actions from a catalog of 11 possibilities. This minimizes the chance of using an expensive remedy, such as contempt, which requires activity by attorneys, in cases where that option is not likely to result in payment.

Simplifying eligibility verifications in San Diego County

Caseworkers today often must manually verify beneficiaries’ eligibility by fetching data from multiple systems. In San Diego County, for example, caseworkers use two different systems for eligibility verifications. The first stores all the required documents to verify eligibility. The second has 500 different application forms; each form, or combination of forms, requires different documents.

Because these two systems don’t share information, caseworkers had to open forms from one system and then look for supporting documents in the other. Since there are 500 forms, these requirements create hundreds of business rules, which a caseworker had to verify manually. The process was complex and consumed a great deal of time.64

To automate the process and connect both systems, the county deployed RPA software. It looks at the open forms on a caseworker’s screen, sifts through the verification fields, identifies relevant documents, and then pulls up those documents from the other system. The entire manual task was replaced with the stroke of a hot key. Thanks to RPA, the county slashed the time it takes to approve a SNAP application from 60 days to less than a week.65